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Monday, December 6, 2021

SCOPE OF PRACTICE QUESTIONS : The standard for making NC Physical Therapy scope of practice decisions is analyzing if it satisfies Board Rule 48C .0101 (a) Permitted Practice -which states, “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.” If the Board determines that it does not satisfy Board Rule 48C .0101 (a), if new or additional information is provided to the Board regarding where this is taught in entry-level or continuing education and is routinely practiced by physical therapists, it will review the new information and make a determination.

After discussing the NCBPTE Declaratory Ruling and NC Supreme Court decision regarding dry needling, the Board determined that the definition in the Supreme Court decision included relieving “myofascial pain.” To the extent relief of myofascial pain includes connective tissue it may be included in the practice of dry needling for PTs in North Carolina. The Board responded to Mr. Lazicki with the following:

The Board determined that as noted in the North Carolina Supreme Court decision issued on December 7, 2018, in the case brought by the Acupuncture Board, “dry needling is a treatment that uses physical or rehabilitative procedures, with assistive devices, for the purpose of correcting or alleviating myofascial pain…” Therefore, any utilization of dry needling techniques that satisfy the foregoing language is within the scope of physical therapy practice in North Carolina. As the Board has previously noted, dry needling is an advanced skill for which training beyond entry level education is required. It is incumbent upon the licensee to obtain the appropriate training and education to be competent to perform dry needling. For your reference, the Board has posted document links related to the litigation brought by the Acupuncture Board on the announcements page of the Board's website. https://www.ncptboard.org/app/Announcements/Announcements.php - scroll down the page.

In addition, the following information may be helpful: In response to your emailed question to the NC Board of PT Examiners, I have provided information below that has been sent to many individuals asking similar questions to yours:

In response to your emailed question below to the NC Board of PT Examiners, I will provide a detailed response regarding NC PT and dry needling although it may be more than you asked, it may be helpful to you going forward. There are no specific requirements for the education and training required for performing dry needling by a physical therapist licensee; however please read further below. Here is the current Board response to this question regarding Dry Needling:

“… at its meeting December 11, 2019, the Board determined that as noted in the North Carolina Supreme Court decision issued on December 7, 2018, in the case brought by the Acupuncture Board, “dry needling is a treatment that uses physical or rehabilitative procedures, with assistive devices, for the purpose of correcting or alleviating myofascial pain…” Therefore, any utilization of dry needling techniques that satisfy the foregoing language is within the scope of physical therapy practice in North Carolina. As the Board has previously noted, dry needling is an advanced skill for which training beyond entry level education is required. It is incumbent upon the licensee to obtain the appropriate training, education and be competent to perform dry needling. For your reference, the Board has posted document links related to the litigation brought by the Acupuncture Board on the announcements page of the Board's website. https://www.ncptboard.org/app/Announcements/Announcements.php - scroll down the page.

You would need to assess your competence after obtaining advanced training prior to performing dry needling on patients. More specifically certification is not currently required by the Board; however, if a certification is obtained, it is very useful to keep on file as part of documentation of competence related to the personal practice of dry needling. If a licensee has not obtained advanced training for a technique they would not be considered to meet the requirements noted above.

Dry needling courses are currently approved per the Continuing Competence rules in 12 NCAC 48G .0105 - .0112. I am not able to address questions of payment for physical therapy services as payers, payer policy or employer policy are not under the jurisdiction of the Board. Contacting payers directly or seeking information from APTA or APTA NC may be helpful to you.

At its meeting September 22, 2021, the Board reviewed the following statement by the Federation of State Boards of Physical Therapy Board of Directors and supports this response to questions regarding providing misinformation to patients.

FSBPT promotes scientific data, research, and analyses in understanding health related matters. FSBPT also strongly discourages the spread of misinformation. In consultation with other health care regulatory groups, the FSBPT Board of Directors has issued the following statement:

“Healthcare professionals who generate and spread misinformation or disinformation about the COVID-19 vaccine are putting the public at risk. Because of their specialized knowledge and training, licensed Physical Therapists and Physical Therapist Assistants possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to provide health care in the best interests of their patients and must share information that is factual, scientifically grounded, and evidence-based for the betterment of public health. Spreading inaccurate information contradicts that responsibility, threatens to further erode public trust in health care, and puts all patients at risk.”

After discussing the materials and content of the presentation provided, and whether this technique is routinely taught in entry level and continuing education and routinely performed in practice, the Board determined the following at its December 11, 2019 meeting:

“…Blood Flow Restriction training satisfies the criteria to be included within the scope of physical therapy practice in North Carolina because it is an advanced skill being taught in entry level PT education, taught routinely in continuing educational programs and routinely performed nationally in PT practice. It is incumbent upon the licensee to obtain the appropriate training and education to be competent to perform this technique in a manner that is considered safe and effective for the patient.”

After the discussion, Board and review of information available, the Board provided this response at its December 11, 2019 meeting: “…The standard for making this determination is contained in Board Rule 48C .0101 (a) Permitted Practice, which states, “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.”

The Board determined that the standards of Board Rule 48C .0101 (a) are not met at this time. Therefore, the use of Musculoskeletal Ultrasound for diagnostic purposes or guiding needle placement during dry needling and physical therapy documentation requirements is not currently within the scope of physical therapy practice in North Carolina. Further, clients receiving this technique should not be advised or led to believe they are receiving physical therapy.

If new or additional information is provided to the Board regarding where this is taught in entry-level or continuing education and is routinely practiced by physical therapists, it will review the new information and make a determination.

After reviewing available information and discussing the matter the Board, at its December 11, 2019 meeting, determined a response to the licensee would be the following: The standard against which the question must be analyzed is contained in Board Rule 48C .0101 (a) Permitted Practice - “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.”

At this time, the Board was unable to determine that Radial Pressure Wave treatment satisfies the standards of Board Rule 48C .0101 (a) based on the information reviewed. If new or additional information is provided to the Board regarding where this is taught in entry-level or continuing education and is routinely practiced by physical therapists, it will review the new information and make a determination.

After reviewing available information and discussing the matter, at its December 11, 2019 meeting, the Board determined a response to the licensee would be the following: “The standard against which the question must be analyzed is contained in Board Rule 48C .0101 (a) Permitted Practice - “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.” At this time, the Board was unable to determine that PTs casting patients with the use of rigid cast material satisfies the standards of Board Rule 48C .0101 (a). If new or additional information is provided to the Board regarding where this is taught in entry-level or continuing education and is routinely practiced by physical therapists, it will review the new information and make a determination. It would be helpful if we could speak on the phone to provide additional information or clarification.

The NC PT Practice Act and Board’s Rules apply to the delivery of physical therapy services via telehealth. In response to this question, at its September 12, 2018 Board meeting, the NC Board of Physical Therapy Examiners considered some questions regarding the parameters of using telehealth in the provision of physical therapy services in North Carolina; the Board determined the following general principles will apply:

  • Telehealth is a delivery model for physical therapy services and as such it is not a question of scope of physical therapy practice.
  • PT licensees must comply with the NC PT Practice Act and Board rules when performing physical therapy services using telecommunications.
  • In order to provide physical therapy services to a patient geographically located in NC, the provider of telehealth services must possess an active NC PT license.
  • To address questions of whether a PT licensee or other healthcare provider or nonhealthcare individual must be with the patient in the remote location and the level of expertise that person needs, the answer depends on various factors, including the status and safety of the patient, whether it is an initial evaluation or ongoing treatment, and the complexity of the services being provided.
  • For questions related to the use of telehealth in physical therapy practice in North Carolina that are not answered by these general principles, the Board will continue to respond to questions on a case-by-case basis.

As the use of telehealth in healthcare practice continues to evolve the Board must keep the protection of North Carolina citizens in mind. The Board will utilize current information based on education, training and routine clinical practices of PT licensees to inform responses to questions. I am not able to address reimbursement questions as the Board does not have jurisdiction over payers or payer policy.

At its meeting on December 9, 2020, the Board considered your question regarding PTA performance of manual lumbar traction of the spine using a mobilization belt. The standard for making this determination is contained in Board Rule 48C .0101 (a) Permitted Practice, which states, “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.” After review of the information available on this topic and discussion by the Board, the Board determined that that the standards of Board Rule 48C .0101 (a) are not met at this time at this time. Therefore, the use of manual lumbar traction is not currently within the scope of practice for the PTA in North Carolina.

In response to your question to the NC Board of PT Examiners, at its meeting September 22, 2021, the Board addressed the question, “…is it within the scope of practice for PTs to perform IV removal?” After the Board discussion, and review of information available, the Board provided this response, the standard for making this determination is contained in Board Rule 21 NCAC 48C .0101 (a) Permitted Practice, which states, “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.” The Board determined that removal of IVs is not routinely taught in entry level education or continuing education and is not routinely performed in PT practice which does not meet the Board standard for a procedure to be considered within the scope of practice.

At its meeting September 22, 2021, the Board addressed the question "is it within the scope of practice for students on clinical training to perform internal pelvic floor examinations?” After the Board discussion, and review of information available, the Board provided this response, the standard for making this determination is contained in Board Rule 21 NCAC 48C .0101 (a) Permitted Practice, which states, “Physical therapy is presumed to include any acts, test, procedures, modalities, treatments, or interventions that are routinely taught in educational programs, or in continuing education programs for physical therapists and are routinely performed in practice settings.” The Board determined that performance of internal pelvic floor examinations is not currently routinely taught in PT academic education and therefore does not meet the Board standard for a procedure to be considered within the scope of practice. In addition, students are not yet licensed and would not be performing this type of activity in entry level educational training. Students may observe this type of patient care and it would be appropriate to obtain patient permission while taking part in clinical training.

In response to your emailed question to the NC Board of PT Examiners, I have provided information below that has been sent to many individuals asking similar questions to yours:

In response to your emailed question below to the NC Board of PT Examiners, I will provide a detailed response regarding NC PT and dry needling although it may be more than you asked, it may be helpful to you going forward. There are no specific requirements for the education and training required for performing dry needling by a physical therapist licensee; however please read further below. Here is the current Board response to this question regarding Dry Needling:

“… at its meeting December 11, 2019, the Board determined that as noted in the North Carolina Supreme Court decision issued on December 7, 2018, in the case brought by the Acupuncture Board, “dry needling is a treatment that uses physical or rehabilitative procedures, with assistive devices, for the purpose of correcting or alleviating myofascial pain…” Therefore, any utilization of dry needling techniques that satisfy the foregoing language is within the scope of physical therapy practice in North Carolina. As the Board has previously noted,

dry needling is an advanced skill for which training beyond entry level education is required. It is incumbent upon the licensee to obtain the appropriate training, education and be competent to perform dry needling

. For your reference, the Board has posted document links related to the litigation brought by the Acupuncture Board on the announcements page of the Board's website. https://www.ncptboard.org/app/Announcements/Announcements.php - scroll down the page.

You would need to assess your competence after obtaining advanced training prior to performing dry needling on patients. More specifically certification is not currently required by the Board; however, if a certification is obtained, it is very useful to keep on file as part of documentation of competence related to the personal practice of dry needling. If a licensee has not obtained advanced training for a technique, they would not be considered to meet the requirements noted above.

Dry needling courses are currently approved per the Continuing Competence rules in 12 NCAC 48G .0105 - .0112. I am not able to address questions of payment for physical therapy services as payers, payer policy or employer policy are not under the jurisdiction of the Board. Contacting payers directly or seeking information from APTA or APTA NC may be helpful to you.

The NC Board of PT Examiners responded to this question at its September 22, 2021 meeting and noted that a patient’s ambulatory status is usually included as part of a physical therapy evaluation if the patient is physically and mentally able to participate.

The Practice Act states the following:

(3) "Physical therapist assistant" means any person who assists in the practice of physical therapy in accordance with the provisions of this Article, and who works under the supervision of a physical therapist by performing such patient-related activities assigned by a physical therapist which are commensurate with the physical therapist assistant's education and training, but an assistant's work shall not include the interpretation and implementation of referrals from licensed medical doctors or dentists, the performance of evaluations, or the determination or major modification of treatment programs.

Board Rule 21 NCAC 48C .0201(a) allows the PTA to assist in the practice of physical therapy only to the extent allowed by the PT.

If the physical therapist has performed an evaluation and created the plan of care and goals, delegation of a portion of that plan to the PTA is allowed. In some cases, a PTA progressing a patient to ambulation may be considered a major modification. However, there may be other cases that it would not. For example: There may be times that a physical therapist could evaluate a patient who is not quite ready to ambulate (such as a patient with ankle surgery who is still a little groggy from anesthesia), so the PT cannot perform a “gait evaluation”; however, due to the patient’s prior functional status, diagnosis, physical condition, setting, experience of PTA, and the working relationship between the PT and the PTA, the PT feels comfortable having the PTA progress the patient to gait training without performing an “official gait evaluation” (based on the patient’s age, strength, sitting balance, etc.). Ultimately, the decision and responsibility to make this determination would be up to the judgment of the physical therapist who performed the evaluation, which should always include patient safety at the forefront of the treatment goals and plan-of-care. If the PT feels that a gait evaluation needs to be performed before the PTA initiates gait training, then the PTA should follow the direction of the PT. For a PTA, failure to follow the direction of the PT may be considered practicing beyond the scope of practice and could be a violation of the Practice Act and Board Rules. If the PTA has received direction to begin ambulation with a patient yet believes that upon seeing the patient it would not be safe or effective for that patient, the PTA should not begin the intervention. The PTA is responsible for communicating the status of the patient to the PT if they believe there may be an adverse event and may make minor modifications to the treatment plan consistent with the plan of care. Whether the PT sees the patient for reassessment is up to the PT. Although the PTA is trained to assist the PT and generally does what the PT delegates, the PTA must still rely on his/her own judgment and training regarding safety and standards of care. If the patient were injured, the PTA’s license would be in jeopardy just like the PT’s. PTAs should document communications with the PT regarding recommended actions and notate “per the PT.”

At its September 21, 2020 meeting, the Board affirmed the position that the use of CBD oil in clinical practice is not part of the PT scope of practice. If CBD oil is going to be sold by a PT, it should be made abundantly clear that it is not physical therapy and is unrelated to any PT plan of care. The patient perception must be clear on this issue. Position statement #20 posted on the Board website provides this information. Also see the November 2021 newsletter with an article by Board attorney, David Gadd, on this issue.

In response to your emailed question to the NC Board of PT Examiners, at its meeting September 22, 2021, the Board addressed the question, “…this question, “does first-hand knowledge of the patient means if the patient is being seen by a PTA, to supervise does the PT needs to see them in-person?” While this rule may have been written prior to the advent of electronic medical records when remote access to a patient’s entire record was not available, the intent of the rule is that a patient being treated by a PTA who requires PT supervision and is not onsite or in the same physical area with the PTA has sufficient information to be able to supervise the PTA and assure that the patient receives safe and effective physical therapy care. The medical records alone may not be sufficient to become familiar with that patient. An in-person visit or virtual visit may be required. While there are circumstances where an in-person visit may not be required by the PT to assure they have first-hand knowledge of the patient for safe and effective care to be taking place it is the responsibility of the PT to do whatever is required to assure appropriate patient care management and oversight of any delegated portions of the plan of care. If a PT supervising a PTA needs to be out for the day or is leaving a practice, it is incumbent upon the PT to assure the care is transitioned to another supervising PT and that transition is documented. If a licensee does not have first-hand knowledge it should be sought before treating or supervising a PTA, Aide or student.

The Board, at its March 11, 2021 meeting, affirmed that performing vaccinations is not in the PT Scope of Practice, thus a licensee is not performing physical therapy and should not imply to a client that they are receiving physical therapy services if they are performing vaccinations. Because vaccinations are not considered in the scope of PT practice, there are no regulations for the Board to modify or waive related to individuals who may perform vaccinations. Specifically, to address the questions regarding students, students are not licensees, thus they would need to obtain the appropriate training, become competent to perform vaccinations and follow all applicable state laws in the same way that PT licensees would do so.

The Board guidance, which will be posted on the Board website, www.ncptboard.org, will state: “In response to emailed questions to the NC Board of PT Examiners, giving vaccinations would not be considered within the scope of PT practice; however, it will not be considered a violation of the NC PT Practice Act or Board rules for a PT licensee to perform vaccinations if they have the proper education, training, are competent to do so and it is safe for the recipient. In addition the licensee should follow all other applicable state laws regarding providing vaccinations. If a PT licensee is performing vaccinations they would not be called PT, nor is a PT license being used when providing the vaccination. A licensee should therefore avoid creating the perception that what they are doing is physical therapy.”

The Board has been made aware of these potential training resources as follows:

The Board also encourages licensee to seek other volunteer options to help support the vaccination effort and slowing the spread of COVID-19: Resource recommended by NCBON - a person can register through “TERMS” – Training Exercise Response Management System - then receive the additional training needed. Link: https://terms.ncem.org/TRS/ Individuals may seek training and opportunities to volunteer through their employers and local health departments.

The Board does not license business entities and is unable to advise you legally about the type of business entity to form. You will go through the NC Secretary of State office to obtain a business license. You can submit your wall certificate copy and copy of your most recent license renewal with your application. The Board does not approve business names or have other requirements. In addition, a memo written by our attorney is on the website that may give you some helpful information ( Position Statement). An attorney or accountant may provide additional information regarding business entities should you require it.



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